How to Process a Claim for Health Insurance?

If you're looking to buy health insurance, want to claim something, or learn more about the process, you should read this article. It's a complete guide to the health insurance claim settlement process for anyone curious about them or wanting to learn more about them.

Cashless Health Insurance Claim

A cashless facility is an emergency insurance plan that will help you avail of cashless treatment in a network of hospitals across India. Not having the option to pay out-of-pocket for emergency treatment in an empanelled hospital will give you peace of mind.

A. Planned Treatment

Here's how to file a cashless claim for planned treatment:

1. At least a week before the scheduled treatment date, the policyholder must submit the claim application form to their insurer via the appropriate option - online or offline.

2. The insurer will notify the hospital where you will be receiving treatment about your cashless claim procedure.

3. After the hospital accepts the cashless claim procedure, the policyholder will receive a confirmation mail or SMS. This email or text message has a specific expiration date, and the policyholder must complete his or her treatment within that time frame.

4. At the time of admission, the policyholder must submit or display the confirmation mail or text to the hospital.

5. Following therapy, the insurer will cover the treatment costs.

B. Emergency Treatment

Here's how to file a cashless claim for emergency treatment:

1. The policyholder must notify the insurer as soon as possible after being admitted to the hospital. Most insurance companies provide a 24-hour window for you to contact them.

2. The policyholder will be sent a cashless claim application form, which must be filled out completely and submitted.

3. The claim will be approved by the insurance, and the hospital will be notified.

4. Following therapy, the insurer will cover the treatment costs.

5. If the claim is denied, the insured will be notified within 24 hours of the company's notification.

Health Insurance Reimbursement Claim

If the policyholder chooses to visit a non-empanelled treatment facility, a health insurance reimbursement claim might be filed. In this instance, the cashless health insurance claim option is unavailable. As a result, the insured must first pay all hospital bills as well as other expenses involved with hospitalisation and treatment before claiming compensation. Here's how to file a reimbursement claim:

1. The policyholder must check the bill information after treatment.

2. Within 24 hours of discharge, the bill and associated treatment records must be sent to the insurance company.

3. The bill and documentation will be reviewed and authorised by the insurance company.

4. If the company has a question or the claim is denied, the policyholder will be contacted.

5. Once the insurance company approves the claim, the bill amount will be refunded.

Required Documentation

Whether you are going for Health Insurance Reimbursement Claim or Cashless Health Insurance Claim, your insurance provider will need some documented proof of the treatment. Here’s what you need to provide them to facilitate your health insurance claim settlement process.

1. Health Card

2. Filled Claim Application Form

3. Medical Form or Certificate signed by the doctor

4. Pharmacy Cash Memos

5. Hospital Prescriptions

6. Bills and Receipts

7. Discharge Summary

8. Report of Investigation

9. FIR or MLC (in case of an accident injury)

Conclusion

Finally, the health insurance claim settlement process is going to be different for everyone. It depends on your insurer and the type of claim you are making. There are no set rules that every company is going to follow. However, every company will have a general procedure that they follow that you can use as a guideline when filing a claim, or if you want to track the progress of your claim.